Title Page

  • Conducted on

  • Prepared by

  • Location


  • Screener is present at the entrance of the facility

  • Screener has appropriate PPE worn (e.g. surgical mask is worn properly)

  • Patients were observed to be screened properly with infrared thermometer

  • Tape/Markers are intact and visible for patients to see

Appointment Check in Area

  • Desks during check - in are clean and clear of unnecessary items?

  • Employees have surgical masks properly worn?

  • Employees are observed to be performing hand hygiene and do not have gloves worn during patient interaction

  • Payment transactions occur one way - meaning the employee is not touching debit cards and giving it back to patient

Waiting Area

  • There are less than 5 people in the waiting area

  • All patients are displaying appropriate social distancing (more than 6 ft) apart. This may exclude Parent/Child/Caregivers

  • Patients have masks or a face covering worn

Clinic - Break Room - Pit Area

  • Hand sanitizers are appropriately stocked inside and outside exam rooms

  • PPE is properly stocked and available for health care personnel use

  • Exam room appears to be clean and ready for patient use

  • Staff is appropriately using surgical masks during shift

  • Healthcare providers have surgical masks and eye protection worn during visit with patient

  • Staff is observed to perform hand hygiene prior to entering and leaving patients room

  • Pit/Work area is clean and presentable (If there is open food in the pit area please put 'no')

Exiting the Facility

  • There is no overcrowding of patients as they exit the premises.

  • The hazardous waste storage rooms are closed and properly secured

  • Exiting appears safe with no object blocking the hallways and exiting pathways

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.